Guideway tailors its post‑discharge activation program to each of the Hospital Readmission Reduction Program conditions – acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective hip/knee replacements. Within days of discharge, our Activation Care Guides connect with patients via phone and SMS, gather feedback on their stay, and proactively address the barriers that cause readmissions in these high‑profile cohorts. By combining Guideway’s Motivational Patient Guidance (MPG) framework with AI‑powered GPS tasking, we ensure that patients receive personalized support during the critical 30‑day window.
What We Do
Conduct condition‑specific teaching and reinforcement on triggers, medication regimens and lifestyle changes.
Identify early clinical warning signs (e.g., chest pain, shortness of breath) and ensure prompt escalation.
Confirm follow‑up visits with cardiologists, pulmonologists, surgeons, or primary care providers.
Address SDOH barriers such as transportation, affordability and access to rehabilitation services.
Monitor adherence to discharge instructions and coordinate care across the continuum.
Benefits
Lower unplanned readmissions across all HRRP conditions.
Reduction in HRRP penalty exposure.
Improved adherence to condition‑specific care plans.
Early detection of clinical deterioration.
Greater patient confidence and satisfaction.
Increased downstream specialty referrals within your network.
Enhanced market share through better care transitions.
One Solution. Enterprise-Wide Patient Activation Impact.
[widgets_on_pages id=”builder-6″]
Decrease HRRP penalties
MPG begins by understanding each patient’s personal motivators and worries.
For example, one patient might be driven by fear of hospital bills (loss aversion) while another is motivated by the desire to stay independent at home. Our solution identifies these multi-dimensional motivators through assessments and conversation, then tailors messaging accordingly. This ensures that outreach isn’t one-size-fits-all but rather speaks to “why” each patient will take action.
Improve HCAHPS scores
Information and motivation alone aren’t enough if a patient is blocked by real-life obstacles.
MPG therefore gives equal weight to Practical Ease—removing barriers like transportation, scheduling confusion, or financial constraints. For example, when required, we use an activation oriented, Stressor Inventory process; our Activation Agents uncover non-clinical issues (lack of a ride to the clinic, difficulty affording medications, etc.) and mobilize solutions proactively. By clearing these hurdles, we make it as easy as possible for patients to follow their care plan.
Decrease care navigation expense
The MPG framework is built on 9 core behavioral techniques that drive action. Among others, these include methods like:
Motivational Interviewing to evoke patient goals and address ambivalence
Social Proof & Community Norms leveraging positive peer examples
Contrast & Framing highlighting the costs of inaction vs benefits of action
Choice Architecture & Micro-Commitments highlighting the costs of inaction vs benefits of action
Each technique is rooted in well-established psychology, and together they cover the full spectrum of persuasion and behavior change needed to move a patient from intention to adherence. Our Activation Agents are extensively trained in applying these MPG principles during patient interactions, ensuring every conversation or message is crafted to maximize its motivational impact.
Improve patient acquisition and retention
The MPG framework is operationalized by our AI-powered Enterprise GPS platform, which acts as the brain continuously monitoring and guiding patient journeys.
The system performs Continuous Motivational Profiling—learning which messages resonate best with each patient (e.g. emphasizing avoiding a negative outcome versus gaining a positive reward). It also uses data-driven segmentation to determine the right intensity of support for each patient (some may just need an automated text, others a phone call or in-home visit). As new data comes in (e.g. a patient misses a call or reports a new concern), the AI rules engine adjusts the plan in real time, selecting the next best action or escalating to a human Activation Agent when needed. This dynamic, closed-loop system means patients get timely, context-aware support instead of static workflows.
Increase clinical capacity
The activation psychology-based MPG approach is not just theoretical. It has been tested and refined in real healthcare environments.
Each of the nine building blocks has demonstrated success in practice, and our platform has over a decade of patient data informing its rules. For example, using Ease & Effort Minimization tactics like scheduling follow-up appointments for patients (instead of leaving it to them) has dramatically improved appointment adherence. Techniques like Relational Communication (empathetic listening and rapid response) have led to greater patient trust and willingness to share issues—allowing problems to be solved before they lead to readmissions. This evidence-based refinement process means the MPG framework reliably produces activation success across diverse patient populations.
Reduce patient leakage
The activation psychology-based MPG approach is not just theoretical. It has been tested and refined in real healthcare environments.
Each of the nine building blocks has demonstrated success in practice, and our platform has over a decade of patient data informing its rules. For example, using Ease & Effort Minimization tactics like scheduling follow-up appointments for patients (instead of leaving it to them) has dramatically improved appointment adherence. Techniques like Relational Communication (empathetic listening and rapid response) have led to greater patient trust and willingness to share issues—allowing problems to be solved before they lead to readmissions. This evidence-based refinement process means the MPG framework reliably produces activation success across diverse patient populations.
Streamline appointment setting
The activation psychology-based MPG approach is not just theoretical. It has been tested and refined in real healthcare environments.
Each of the nine building blocks has demonstrated success in practice, and our platform has over a decade of patient data informing its rules. For example, using Ease & Effort Minimization tactics like scheduling follow-up appointments for patients (instead of leaving it to them) has dramatically improved appointment adherence. Techniques like Relational Communication (empathetic listening and rapid response) have led to greater patient trust and willingness to share issues—allowing problems to be solved before they lead to readmissions. This evidence-based refinement process means the MPG framework reliably produces activation success across diverse patient populations.
Five Key Motivational Patient Guidance (MPG) Elements for delivering “the right nudge at the right moment” activate each individual patient to improve clinical and business outcomes.
1. Multi-Dimensional Motivation Focus
2. Practical Barrier Removal
3. Nine Behavioral Activation Techniques
4. AI-Orchestrated Personalization
5. Validated in Real-world Settings
One Solution. One Focus. Every patient’s next right action.
At Guideway Care, we are the Patient Activation Company. We do one thing extremely well: we activate patients—ensuring they take the next right step—regardless of the challenge. Our AI‐powered, activation psychology‐driven solution fuses advanced technology, motivational patient guidance, and specialized human insight to overcome both practical and psychological barriers, delivering transformative financial and clinical outcomes.
Whether we are reducing readmissions by 35%, boosting appointment adherence to near 100%, or lifting patient satisfaction scores by 31%, our overwhelming activation evidence shows that our integrated solution delivers unmatched clinical and financial outcomes where traditional engagement methods have failed.
One Solution for Evidence-Based Patient Activation
Improve Financial and Clinical Outcomes Across the Enterprise
Motivational Patient Guidance Framework for Activation Success
A Comprehensive Guide to Motivational Patient Guidance and Activation Psychology
How much more awareness do you have of how to properly escalate and manage symptoms since participating in the program (scale 1-10)?
One Solution. One Focus. Every patient’s next right action.
At Guideway Care, we are the Patient Activation Company. We do one thing extremely well: we activate patients—ensuring they take the next right step—regardless of the challenge. Our AI‐powered, activation psychology‐driven solution fuses advanced technology, motivational patient guidance, and specialized human insight to overcome both practical and psychological barriers, delivering transformative financial and clinical outcomes.
Whether we are reducing readmissions by 35%, boosting appointment adherence to near 100%, or lifting patient satisfaction scores by 31%, our overwhelming activation evidence shows that our integrated solution delivers unmatched clinical and financial outcomes where traditional engagement methods have failed.
Close the Gap with Evidence-Based Patient Activation
It’s time to close the engagement gap in your organization.
Don’t settle for costly programs that maintain the status quo. Download our Short Guide to Evidence-Based Patient Activation to learn how Guideway Care can drive better outcomes and financial performance for you. See the data, case studies, and model behind this proven solution – and discover how to finally achieve the patient engagement breakthrough your team has been looking for. Get the guide now and start your journey to real patient activation and real results.
It has been a little more than two years since the United States Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). Since that historic decision, hospitals have felt the pinch thanks to performance-based penalties levied by the federal government.
Regulations are stricter, penalties continue to increase and hospital administrators are facing shrinking bottom lines. Medical professionals are taxed and the general public is living an unhealthy lifestyle. Obesity is becoming an epidemic, creating more patients in an all ready crowded space.
The solution is not admitting patients to the hospital, fixing them and sending them back into the world. The key is patient engagement and education.
Guideway Care is transforming the patient experience. When hospitals team with us, they are in constant contact with the patient. Hospitals are engaged with the patient and manage the patient throughout the hospital stay and remain in contact after the patient goes home.
Patients get the care they deserve, and hospitals avoid costly penalties created by the healthcare law.
When PPACA came into existence, the Centers for Medicare & Medicaid Services (CMS) set guidelines regarding excessive readmissions of Medicare patients within 30 days of being discharged from the hospital. It was called the Hospital Readmissions Reduction program and reduced Medicare payments for excess readmissions beginning Oct. 1, 2012.
According to a report from Kaiser Health News, in the first year of the mandate, 2,211 hospitals lost payments because of excess readmissions in 2013. Kaiser reported a total of $280 million was lost due to CMS penalties. Specifically the report found 278 hospitals lost 1 percent of their base Medicare payments, then the maximum allowed by the healthcare law. Nearly two thousand hospitals lost a percentage of 1 percent of their base Medicare payments in the first year of the law.
Last year, nearly 18 percent of Medicare patients, who had been hospitalized, were readmitted within a month. Roughly 2 million patients return a year, costing Medicare $26 billion. Officials estimate $17 billion of the cost comes from potentially avoidable readmissions.
Federal records released on Oct. 8 showed Medicare is fining a record number of hospitals – 2,610 – for having too many patients return within a month for additional treatments. Even though the nation’s readmission rate is dropping, Medicare’s average fines will be higher, with 39 hospitals receiving the largest penalty allowed, including the nation’s oldest hospital, Pennsylvania Hospital in Philadelphia.
Under the new fines, three-quarters of hospitals subject to the Hospital Readmissions Reduction Program are being penalized. From Oct. 1 through next Sept. 30, they will receive lower payments for every Medicare patient stay — not just for those patients who are readmitted. Over the course of the year, the fines will total about $428 million, Medicare estimates.
The healthcare law was designed to improve healthcare in America and increase access to get affordable healthcare for patients. The levied penalties were designed to curb rising medical costs and encourage hospitals to improve performance and manage expenses more efficiently by preventing patient readmissions.
Clearly the fines aren’t working.
However, what does work is patient education and maintaining a relationship with the patient from initial contact and patient intake to post-procedure care, hospital discharge, follow-up visits and other outreach efforts.
When a patient was discharged, hospitals offered paper instructions and reminded the patient to follow up with his or her doctor in a couple of weeks. It is no wonder readmissions are costing hospitals millions.
Teaming with Guideway Care, hospitals offer more than a piece of paper and well wishes. Patients gain access to ongoing patient education, health and wellness coaches, preventive reminders and care coordinators who remind the patient of follow-up doctor visits.
Hospitals are learning the hard way – financial penalties – care doesn’t end when the patient leaves the hospital. More active efforts are required and Guideway Care can meet those requirements. With our help, patients avoid readmission and the hospitals avoid financial penalties. It’s a win-win situation.
Don’t delay, call or schedule a demo today.
We use cookies and similar technologies to improve your experience on our website.
Read our Privacy Policy.